CAROLINAS REHABILITATION

Transcription

1 CAROLINAS REHABILITATION CURRENT LANGUAGE ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) New Language ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) ARTICLE II - PART I: CMC-C CANCER COMMITTEE: Section 1: The CMC-C Cancer Committee of Carolinas HealthCare System is a committee established for the purpose of overseeing and coordinating the cancer program. The CMC-C Cancer Committee shall be responsible and accountable for setting goals, planning, initiating, implementing, evaluating and improving all cancer program activities within Carolinas HealthCare System in accordance with the standards set forth by the American College of Surgeons Commission on Cancer Approvals Program (the Accreditation Standards ) and for ensuring that all cancer program activities fully comply with the Accreditation Standards. Section 2: When requested, the CMC-C Cancer Committee shall review and evaluate, in accordance with guidelines, as set forth by the American College of Surgeons (ACOS), the quality of Hospital or health care services provided in the treatment of cancer patients, as described by National Comprehensive Cancer Network (NCCN) guidelines. Section 3: The CMC-C Cancer Committee shall meet as often as necessary to fulfill its duties, shall maintain a permanent record of its findings, proceedings and actions, and shall make a written report thereof after each meeting to the Facility Medical Executive Committee and the President of the Hospital. Section 4: The CMC-C Cancer Committee will report to the respective Hospital Quality Assessment and Improvement Committee regarding the appropriate clinical management of individual cancer patients only when asked to do so by a member of the Medical Staff, Risk Management, or the Chairman of the Quality Assessment and Improvement Committee. The Cancer Committee will serve a support role to the Quality Assessment and Improvement Committee in this regard. 1

2 ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) New Language ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) ARTICLE II: MEDICAL STAFF COMMITTEES AND FUNCTIONS ARTICLE II - PART F: ELECTRONIC MEDICAL RECORDS COMMITTEE: SECTION 1. COMPOSITION: (a) (b) The Electronic Medical Records Committee shall be multi-disciplinary, consisting of Medical Staff Appointees representing various clinical specialties; The President of the Medical Staff shall appoint one (1) member of the Committee to serve as chairperson of this Committee. ARTICLE II - PART F: ELECTRONIC MEDICAL RECORDS COMMITTEE: SECTION 2. DUTIES: The Electronic Medical Records (EMR) Committee shall supervise the maintenance of Electronic Medical Records at the required standard of The Joint Commission and all other state and/or federal regulatory bodies as applicable. The Committee shall evaluate results of the medical record reviews and audits to ensure compliance with the Bylaws of the Medical and Dental Staff. This evaluation will include all aspects of EMR usage. ARTICLE II - PART F: ELECTRONIC MEDICAL RECORDS COMMITTEE: SECTION 3. MEETINGS, REPORTS, AND RECOMMENDATIONS: The Electronic Medical Records Committee shall meet as often as necessary to fulfill its duties, but at least quarterly; shall maintain a permanent record of its findings, proceedings, and actions; and shall make a written report thereof after each meeting to the Facility Medical Executive Committee and the Administrator of the Hospital. The EMR Committee shall also report (with or without recommendation) to the Chief of the Specialty, and as appropriate, the Quality Assessment and Improvement Committee or the Facility Credentials Committee for it s consideration and appropriate action regarding any situation involving questions of any EMR usage that is determined to be less than optimal or appropriate. 2

3 1. ADMISSION 2. Admitting Appointee's Responsibilities: a. Unless medical circumstances dictate otherwise, all patients admitted to a CR Facility shall have a provisional diagnosis and specific rehabilitation goals and treatment plan clearly delineated upon admission. During hospitalization, the attending Physician will attend patient planning conferences, team and family conferences, and coordinate care with the other members of the rehabilitation team. b. All patients shall be attended by members of the Medical Staff and shall be assigned to the appropriate specialty concerned in the treatment of the condition. Each patient's general medical condition is the responsibility of a qualified member of the Medical Staff. c. Members of the Medical Staff admitting and attending patients shall be held responsible for getting as much information as may be necessary to assure the protection of the patient from self-harm and to ensure the safety of other patients in the applicable CR Facility. 1. ADMISSION 2. Admitting Appointee's Responsibilities: a. Unless medical circumstances dictate otherwise, all patients admitted to a CR Facility shall have a provisional diagnosis and specific rehabilitation goals and treatment plan clearly delineated upon admission. During hospitalization, the attending Physician will attend patient planning conferences, team and family conferences, and coordinate care with the other members of the rehabilitation team. b. All patients shall be attended by members of the Medical Staff and shall be assigned to the appropriate specialty concerned in the treatment of the condition. Each patient's general medical condition is the responsibility of a qualified member of the Medical Staff. c. Members of the Medical Staff admitting and attending patients shall be held responsible for getting as much information as may be necessary to assure the protection of the patient from self-harm and to ensure the safety of other patients in the applicable CR Facility. d. Non Critical Care Patients: Patients admitted and who are routinely seen by Allied Health Professionals must be seen by the attending or assigned physician and a progress note written at least three (3) times a week. e. In the event that the condition of a patient changes or as requested by an Allied Health Professional, the attending or assigned physician shall see the patient as clinically indicated, but at least within twelve (12) hours of such change in condition or request. In accordance with Article II, Part D, Section 1 of the Policy on Clinical Privileges for Allied Health Professionals, Supervising Physicians are responsible for the care provided by Dependent Practitioners in the hospital. Furthermore, nothing in this section alters the underlying expectation that all members of the Medical Staff maintain ongoing communications with Allied Health Professionals as appropriate to address the patients condition and to assess treatment needs. 3

4 II. MEDICAL ORDERS 2. Who May Write Orders: Orders for medication and treatment may be written by members of the Medical Staff and others involved in the care of the patient and others who may have been authorized to do so by the granting of Temporary Privileges or as Locum Tenens. Orders dictated over the telephone will be signed by the person who received the orders with the Physician's name per his or her own name. Orders for treatment may also be written by members of the House Staff (residents and fellows in training) pursuant to policies established by the Division of Education and Research. Members of the House Staff may write patient care orders, with the exception of orders for a no-code, which must be written by the attending Physician of record. Counter signature by a member of the Medical Staff is required on the discharge summary. The following individuals are authorized to accept and transcribe verbal orders in their respective discipline: Independent Practitioner Dependent Practitioner Recreational Therapists Medical Students Serving as Acting Interns Cognitive Education Specialists II. MEDICAL ORDERS 2. Who May Write Orders: Orders for medication and treatment may be written by members of the Medical Staff and others involved in the care of the patient and others who may have been authorized to do so by the granting of Temporary Privileges or as Locum Tenens. Orders dictated over the telephone will be signed by the person who received the orders with the Physician's name per his or her own name. Orders for treatment may also be written by members of the House Staff (residents and fellows in training) pursuant to policies established by the Division of Education and Research. Members of the House Staff may write patient care orders, with the exception of orders for a no-code, which must be written by the attending Physician of record. Counter signature by a member of the Medical Staff is required on the discharge summary. The following individuals are authorized to accept and transcribe verbal orders in their respective discipline: Independent Practitioner Dependent Practitioner Recreational Therapists Medical Students Serving as Acting Interns Cognitive Education Specialists The following individuals may document in a patient record: The following individuals may document in a patient record: All members of the Medical Staff Locum Tenens Physicians with temporary privileges Independent Practitioners Dependent Practitioners Nursing Staff All members of the Medical Staff Locum Tenens Physicians with temporary privileges Independent Practitioners Dependent Practitioners Nursing Staff 4

6 ARTICLE II. - RULES AND REGULATIONS SECTION OF THE BYLAWS SECTION II. MEDICAL RECORDS 1. General Rules: Members of the Medical Staff shall be held responsible for preparation and completion of the medical record for the Hospital files within a reasonable length of time, as designated herein 2. Authentication: All medical records must be authenticated by the responsible Practitioner. All entries in the medical record, including all orders, must be timed as well as dated. 3. Contents: The contents of the medical record must include identification data, complaint, personal history, family history, chief complaint, history of present illness, physical examinations, and special reports such as consultations, clinical laboratory, x-ray, electrocardiographs, and others. Provisional diagnosis, medical and/or surgical treatment shall also be included along with the pathological findings, progress notes, final diagnosis, discharge summary, and, if performed, autopsy reports. 4. History and Physical: An adequate history and physical examination shall be completed and recorded within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery. If the history and physical is dictated, an admission progress note indicating the reason for admission and a plan for evaluation and treatment must be recorded on the chart within twenty-four (24) hours after admission of the patient. The history and physical shall be consistent with normally accepted professional standards and Joint Commission requirements. If a history and physical has been completed by the attending Physician/Oral Surgeon within thirty (30) days prior to admission, a signed, dated and timed, durable, legible copy of this report may be used in the patient's medical record provided there has been no subsequent change as noted in an update to the history and physical that is signed, dated and timed within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery or the changes have been recorded in an update note to the history and physical that is signed, dated and timed within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery. A Short Form History and Physical may be substituted for the complete History and Physical for admissions to Observation Units, and for other admissions which are not anticipated to extend past forty-eight (48) hours. ARTICLE II. - RULES AND REGULATIONS SECTION OF THE BYLAWS SECTION II. MEDICAL RECORDS 1. General Rules: Members of the Medical Staff shall be held responsible for preparation and completion of the medical record for the Hospital files within a reasonable length of time, as designated herein 2. Authentication: All medical records must be authenticated by the responsible Practitioner. All entries in the medical record, including all orders, must be timed as well as dated. 3. Contents: The contents of the medical record must include identification data, complaint, personal history, family history, chief complaint, history of present illness, physical examinations, and special reports such as consultations, clinical laboratory, x-ray, electrocardiographs, and others. Provisional diagnosis, medical and/or surgical treatment shall also be included along with the pathological findings, progress notes, final diagnosis, discharge summary, and, if performed, autopsy reports. 4. History and Physical: An adequate history and physical examination shall be completed and recorded within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery. If the history and physical is dictated, an admission progress note indicating the reason for admission and a plan for evaluation and treatment must be recorded on the chart within twenty-four (24) hours after admission of the patient. The history and physical shall be consistent with normally accepted professional standards and Joint Commission requirements. A history and physical examination may be performed by an Allied Health Professional if stipulated in the Allied Health Professional s approved delineation of privileges form and in accordance with North Carolina law. A history and physical examination performed by an Allied Health Professional shall be countersigned by an attending Physician/Oral Surgeon or additional supervising physician/oral surgeon in accordance with Hospital Policy. If a history and physical has been completed by the attending Physician/Oral Surgeon within thirty (30) days prior to admission, a signed, dated and timed, durable, legible copy of this report may be used in the patient's medical record provided there has been no subsequent change as noted in an update to the history and physical that is signed, dated and timed within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery or the changes have been recorded in an update note to the history and physical that is signed, dated and timed within the earlier of (1) twenty-four (24) hours after admission or (2) prior to surgery. A Short Form History and Physical may be substituted for the complete History and Physical for admissions to Observation Units, and for other admissions which are not anticipated to extend past forty-eight (48) hours. 6

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